If the paroxysms increase in violence, occur earlier, and become much stronger; if they invade on the third day; and if symptoms of concoction appear in the urine, alvine discharges, and sputa, the disease will certainly soon come to a crisis. If the attack is slow, and if the paroxysms occur at the same hour every day, you may expect that the crisis will not take place till after a longer time. And those fevers which make their attack with rigors cannot terminate until the rigor abate; for until that occur it is impossible for the disease to have attained its acme, and therefore much less is it reasonable to expect that it is upon the decline.
Commentary. This Section is copied from Oribasius. (Synops. vi, 3.) The subject is fully treated of by Galen (de Crisibus.) Rhases describes very accurately the symptoms of an approaching crisis, such as, confusion of the understanding, vertigo, headach, inquietude, involuntary flow of tears, pain of the stomach, &c. He warns the inexperienced not to be alarmed at the violence of the precursory symptoms. (x, 26.) Avicenna, Averrhoes, Haly Abbas, and Alsaharavius, though they treat of the subject very fully, supply no original views.
See an ample account of the ancient opinions in Prosper Alpinus. (De Præs. Vita et Morte ægrot. vi.)
SECT. X.—HOW TO RECOGNIZE A PRESENT CRISIS.
Restlessness precedes every crisis, and if the crisis be to take place by day, it will occur by night; or if the crisis be to take place during the night, it will occur by day; and then certain symptoms supervene, such as headach not previously occurring, sympathetic pain of the neck, retraction of the hypochondrium, sudden difficulty of breathing, and other dangerous symptoms which did not manifest themselves before then take place. And if, when these occur, the pulse, instead of sinking, is increased in magnitude and becomes stronger, and the critical day approaches, and if it be one of the favorable, you may not only anticipate a crisis, but also a good one. And be not then alarmed if you see the patient become delirious and disturbed, for these are indications of the humours being carried upwards; in like manner as certain other symptoms indicate their being determined downwards, such as pain of the belly, gripes about the navel, pain in the loins, borborygmi, and other similar symptoms, when they occur. In addition to these, if the patient was accustomed to have a hemorrhoidal discharge, and if the period of it be at hand, and in like manner with respect to the menstrual discharge (if the patient be a woman), it is not unlikely that the crisis may take place by such an evacuation. And a critical sweat is recognized by a precursory moistness of the skin (especially if occurring upon one of the days called indicatory), and by openness of the pores. From these you may recognize crises by evacuations upwards; for, in addition to the aforesaid, you ought to examine the face of the patients, and whether there be palpitation in any part, or throbbing of the temporal arteries; or if the cheek, nose, or eye be redder than usual, you ought the rather to anticipate the coming crisis. But if they shed tears involuntarily, or fancy that they see sparks of light, and constantly carry their hands to their nose as if to rub it, then indeed you may see not only an approaching but a present flow of blood; for when they rub it once or twice the blood straightway breaks forth. Pungent pain at the stomach, and trembling of the under-lip often indicate a crisis by vomiting. These considerations are sufficient, but to them may be joined the age and constitution of the patient, as strengthening the anticipation; to which may be added, the season of the year and the present constitution. For if the patient be a child, or otherwise by nature warm and full of blood, you may still more form this anticipation; or if formerly, when in health or disease, as we remarked before, an evacuation of blood appeared, this circumstance alone may be sufficient to make you expect a hemorrhagy. And if the season of the year be summer, or, if not summer, if the present state of the weather be hot, and if the patient had often experienced a crisis at that season by hemorrhage, if the body be plethoric, if there is retention of the customary evacuations, all these things ought to strengthen your expectations. In like manner you ought to judge of the other evacuations; or, if none of these symptoms should appear, but if there be uneasiness occurring on one of the critical days after the 20th; or if, when the disease is at its acme, pains should seize certain joints, or near the ears, or in other parts; or if not pains, but local sweats should occur unceasingly in any part of the body, then indeed you may expect a crisis to take place by abscess, and in that part where the sweats, pains, or swelling occurred.
Commentary. This is taken with very slight alterations from Galen (Therap. ad Glauc. i: see also, de Crisibus, iii, 2.) The critical evacuations enumerated by Galen are, those by vomiting, by the belly, by urine, by sweats, by hemorrhage from the nose, by hemorrhoids, by the menses in women, by abscesses of the parotid glands, and by determination to the knees, feet, or some other parts not vital. He says there are three ways in which a fever may terminate favorably, namely, by an evacuation, by an imperfect crisis without an evacuation, and by resolution, that is to say, when the febrile symptoms go off gradually. There are likewise three unfortunate terminations; for the patient may die suddenly with much agitation, or in consequence of a metastasis, or he may be slowly wasted by a marasmus.
Averrhoes enumerates the same kinds of critical evacuation as Galen, and otherwise treats of them very judiciously. (Collig. iv, 39.) Avicenna gives a long account of all the circumstances attending the crisis, but he copies closely from Galen and Hippocrates. (iv, 2, 1.) Haly Abbas, in like manner, is sensible and correct, but borrows from the Greeks. (Theor. x, 10.) The account given by Rhases is excellent, but it differs little from our author’s. (Ad Mansor. x, 27.) In his ‘Continens,’ he gives a full exposition of the Galenic doctrines, with his own Commentaries. He states, that a crisis may take place in six ways: by hemorrhage at the nose, by an alvine evacuation, by vomiting, by a discharge of urine, by a sweat, or by an aposteme. (xxxi.)
SECT. XI.—HOW TO DETERMINE WHETHER A PAST CRISIS BE FAVORABLE.
If a proper evacuation takes place after the concoction, and the fever is resolved by the critical evacuation; if the patient is freed from all other symptoms; if his colour has improved in proportion to the evacuation; if his pulse has become more regular, and his strength better in rising out of bed; and, what is the most salutary symptom of all, if these are accompanied by repose of the constitution, this may be pronounced to be the best possible crisis. If any of these be wanting, the goodness of the crisis will diminish proportionally to the force of the diminution.